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Provider Update Newsletter
September 2006, Volume 167
All Providers
Dental Care for Kids
Program of All-Inclusive Care for the Elderly (PACE)
Prior Authorization & Fax Number Changes
Pharmacy Providers
EDS & Rhode Island Pharmaceutical
Assistance to the Elderly (RIPAE) Program
DME Providers
Changes in DME/Pediatric Prior Authorization
Process
Dental Care for Kids
Rhode Island is starting a new dental program called
RIte Smiles for young children born on or
after May 1, 2000 who are eligible for Medical Assistance (RIte Care,
RIte Share or Medical
Assistance fee-for-service). Eligible children from birth to five will
initially be enrolled and as children
reach their sixth birthday, they will continue in the program, so each
year the age of the children in
the program will increase.
RIte Smiles is designed to increase access to dental care for
children on Medical Assistance and
help prevent serious oral health problems, as kids get older. To do
this, the State has contracted
with UnitedHealthcare Dental to provide a dental network and member
services. UnitedHealthcare
Dental will be contacting dentists throughout the State to become a part
of this new dental plan.
The Department of Human Services will be enrolling approximately 30,000
children into United-
Healthcare Dental over a period of three months. The first
group will be enrolled on September 1,
2006. We hope to have many Rhode Island dentists participate in the RIte
Smiles Program.
If you are interested in participating please call the UnitedHealthcare
Dental recruitment line at
1-888-679-8923. For more information on RIte Smiles, click
here.
Program of All-Inclusive Care for the
Elderly
PACE began providing care to RI recipients in late
2005. If a recipient is eligible for PACE, they
have elected to receive all of their care from a PACE provider. PACE
arranges for all of the recip-
ients’ care and reimburses their providers directly.
If a recipient is on PACE, the recipient is no longer eligible to
receive services under Medical Ass-
istance Fee For Service (Medicaid).
If you are checking eligibility, and you hear under other insurance
“Program for All-Inclusive Care for
the Elderly,” this means that if you provide care to the recipient you
will not be reimbursed by Medical Assistance. This recipient is not
eligible for Medicaid services. The recipient should be referred to
PACE, and they will arrange for any treatment that is required.
If you do provide service to a PACE recipient and you bill RI Medical
Assistance your claim will be
denied.
If you have any questions regarding eligibility, please contact the
Customer Service Help Desk at 401-
784-8100 or 1-800-964-6211 for in-state toll calls.
Prior Authorizations & Fax Number Changes
Please note for your convenience, EDS has added an
additional fax machine for submission of
Prior Authorizations (PA).
MDS forms as well as requests for VNA, Vision, Dental, Out Patient and
Behavorial/Mental
Health
should be faxed to 401-784-8828.
Please do not use 941-7712 to send your fax request to EDS.
Prior authorization requests for Durable Medical Equipment (DME) should
be mailed to:
EDS
Prior Authorization Department
PO Box 2006
Warwick, RI 02886
If you need to change information on a PA that has
already been approved for DME, you may
do so via fax. However, original requests must be sent in on paper.
The fax number for Transportation faxes has not changed, fax requests
should still be sent to 401-
467-9581.
If you are not sure where to send your faxes, please contact the
Customer Service Help Desk at
401-784-8100 or 1-800-964-6211 for in-state toll calls.
EDS & Rhode Island Pharmaceutical Assistance
to the Elderly (RIPAE) Program
This is to serve as a reminder that as of July 1st,
2006, the Rhode Island Department of Human Ser-
vices and its fiscal agent, EDS, has replaced BioScrip as the Pharmacy
Benefits Manager for the
Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) program.
This change in benefit managers brings with it a few claims processing
changes outlined below.
-
RIPAE recipients have received a new card and
member identification number. This number
replaces their social security number and is a nine digit number
beginning with a 98. The
new number is to be used for Dates of Service of July 1st, 2006 and
later. Claims submitted
with the old social security number after July 1st, will deny with
error message “Recipient
Number M/I or Not on File”.
-
As of July 1st, 2006 claims submitted to RIPAE
must be submitted to EDS with:
BIN: 610471
PCN: RIPAE0706
-
As of July 1st, 2006 claims submitted to RIPAE
must be done so using your RI Medical Ass-
istance provider number not your NABP/NCPDP number.
-
In the event that a RIPAE member has another
insurance, in addition to their RIPAE cover-
age, (ex. Medicare Part D, or any commercial coverage), the other
insurance should be billed
as primary and then a secondary claim should be submitted to RIPAE.
-
Claims submitted directly to RIPAE, where
there is another insurance on file will
deny with “Submit Bill to Other Processor or Other Payer”.
-
Claims billed as secondary to RIPAE where
the primary insurance has not made
payment (either denied or paid $0.00) will adjudicate on through
the RIPAE claims
processing logic. Providing no other edits set, this type of
claim transaction will pay,
posting the member co-payment due by the recipient and the
co-payment information
will be forwarded to the TrOOP facilitator.
-
Claims billed as secondary to RIPAE where
the primary insurance has made pay-
ment (> $0.00) will deny with “Claim Denied, Payment Collected
from Other Payer”
Questions or concerns can be directed either to the Customer Service
Help Desk at (401) 784-8100 or 1-800-964-6211 for in-state toll calls or
contact your Pharmacy Coordinator, Ingelcia G. Simas at (401) 784-3818
or email Ingelcia Simas by clicking
here.
Changes in DME/Pediatric Formula Prior
Authorization Process
As of June 15th, 2006, DME Prior Authorization (PA)
requests will not be accepted through
FAX. New requests must be mailed in via USPS to:
EDS
Prior Authorization Unit
PO Box 2006
Warwick, RI 02887-2006
Only under extreme emergency circumstances will a
faxed request be accepted. In addition, when a
PA request is returned to a provider requesting additional information
the original request along with
the Reason for Return sheet and the requested information should be
mailed back to EDS. A new PA
sheet should not be used. This causes duplication and confusion.
Revisions to existing PAs, sus-
pended or approved, may in fact be faxed to the EDS PA department at
(401) 784-8828.
As of June 15th, 2006 pediatric formula codes B4158, B4159, B4160,
B4161 & B4162 no longer require Prior Authorization (PA). Families
needing these products are still required to bring a signed prescription
to the pharmacy to be kept on file, however PA is no longer required.
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